197604691-9-29-2021-31-AS-NMAN-CBJ2JV-20220210162657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197604691
Report Date: 09/29/2021
Date Signed: 09/29/2021 02:45:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/11/2020 and conducted by Evaluator Jose Gary Tan

COMPLAINT CONTROL NUMBER: 31-AS-20200911123028

FACILITY NAME:	ANGIE'S HOME CARE, INC.		FACILITY NUMBER:	197604691
ADMINISTRATOR:	HEATH, ANGELA		FACILITY TYPE:	740
ADDRESS:	16456 LOS ALIMOS ST		TELEPHONE:	(818) 366-7906
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	4	CENSUS: 4	DATE:	09/29/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Angie Heath - Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained a pressure wound while in care

Resident is malnourished while in care

Staff are not following physician's orders as required

Staff failed to address resident's incontinence needs

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit to the facility to deliver the findings for the above allegation. LPA met with the administrator Angie Heath and explained the purpose of this visit.

Entrance interview conducted.

On 09/11/2020, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to and accepted by Community Care Licensing Division’s Investigations Branch (IB) and assigned to IB investigator Jose Santana.

On 09/14/2020 at 9:11 AM, LPA Tan initiated the complaint visit. LPA Tan interviewed the administrator and obtained copies of the facility records relevant to the investigation.
(continued on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 31-AS-20200911123028

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANGIE'S HOME CARE, INC.	FACILITY NUMBER: 197604691
	VISIT DATE: 09/29/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(continued from LIC 9099)

During the course of subsequent investigation, Investigator Santana interviewed the administrator and resident #1 (R1) on 11/04/2020. Resident #1 (R1)’s Medical Power of Attorney (MPOA) and R1 on 09/16/2020 & 09/17/2020 and 11/05/2020, Los Angeles Police Department (LAPD) officer on 09/22/2020 and 11/05/2020, Long Term Care Ombudsman (LTCO) on 11/02/2020, Reporting Party (RP) on 11/04/2020 and Hospice Licensed Vocational Nurse (LVN) on 11/04/2020. Investigator Santana also subpoenaed Wound Care, Hospice and Hospital records on 09/18/2020 and received on 09/25/2020 and 09/28/2020 in digital format. Investigator Santana also attempted to obtain any record from the law enforcement regarding R1 on the incident but was informed that there was no investigation conducted and the case was closed.

Regarding the allegation the resident sustained a pressure wound while in care, LPA record review on 09/14/2020, revealed that R1 was admitted at the facility on 03/15/2020 and for Hospice care services on 03/25/2020. R1 had hospice nurse’s and certified hospice home aide (CHHA) visit twice a week. On 06/23/2020, the visiting nurse observed that R1 had a sacral pressure injury that the nurse did not observe the prior week. The issue was elevated to the hospice doctor who recommended treatment immediately and increased the frequency of R1’s repositioning. On 07/10/2020, the hospice agency requested a wound consult to the wound care clinic. On 07/14/2020, the wound significantly decreased in size. On 07/16/2020 however, the family member who is also the Medical Power of Attorney (MPOA) of R1 had revoked the services of the hospice agency as R1 had to receive aggressive treatment for R1’s infection in the acute hospital. R1 was again resumed hospice services due to increased weakness, poor appetite, and pressure injury on 08/11/2020 and immediately requested another wound consult the day after (08/12/2020). The Hospice agency continued to treat the wound of R1 until the initial visit of the Wound Care specialist on 08/20/20 who assumed wound treatment of R1.

(continued to LIC 9099-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 31-AS-20200911123028

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANGIE'S HOME CARE, INC.	FACILITY NUMBER: 197604691
	VISIT DATE: 09/29/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(continued from LIC 9099-C)

Regarding the allegation that the resident was malnourished while in care, LPA medical record review revealed that R1 visited hospital clinic on 04/20/2020 and stated that R1 did not have any weight loss. R1 had also visited hospital clinic on 07/15/2020, 07/16/2020, 07/17/2020, 07/20/2020 and 07/24/2020 with multiple doctors including an Internist and there was no observation on record that R1 was malnourished. On 08/05/2020, R1’s visit at the medical center was observed to be negative for weight loss. Moreover, Investigator Santana’s interview with R1’s MPOA revealed that R1 sometime refused to eat lunch but MPOA persuaded R1 not to refuse any meal which R1 agreed.

Regarding the allegation of staff are not following physician’s order as required, Investigator Santana’s interview with R1’s MPOA revealed that the MPOA was told by the administrator and was aware of the doctor’s order to procure low air loss mattress for R1 and eventually procured it. Investigator Santana’s interview with R1 also revealed that R1 was aware that the administrator told R1’s MPOA to buy the required mattress but due to MPOA’s oversight, was not immediately purchased but now R1 is using it.

Regarding the allegation that the staff failed to address resident’s incontinence needs, Investigator Santana’s interview with R1 revealed that caregivers check on R1 at night regularly but sometime refused to wake R1 when R1 is sound asleep. R1 also refused to call caregiver at times during nighttime. Investigator Santana’s interview with MPOA also revealed that MPOA knew that R1 is being changed and turned every two (2) hours as R1 would have told MPOA if they did not.

Based on information gathered during the course of the investigation, the allegations are deemed unsubstantiated at this time

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3